Cognitive and psychosocial outcomes following stereotactic radiosurgery for acoustic neuroma.

BACKGROUND: Acoustic Neuroma (AN) is a benign tumour of the eighth cranial nerve. Stereotactic Radiosurgery (SRS) is a common treatment approach. Studies have explored the primary effects of SRS and documented equivalent efficacy for tumour control compared to neurosurgery. OBJECTIVE: Examine the longer term cognitive and psychosocial outcomes of SRS in non-Neurofibromatosis Type II patients utilising both objective and subjective cognitive outcomes associated with quality of life and health related distress. METHODS: Nineteen individuals treated via SRS were assessed using a battery of standardised psychometric tests as well as measures of quality of life and psychological distress. RESULTS: Participants had largely preserved cognitive function except for processing speed, aspects of attention and visual memory relative to age norms. Self-reported quality of life was better than in other AN population studies. Level of psychological distress was equivalent to general population norms. More than half of participants reported subjective cognitive decline though this was not fully supported by objective testing. Subjective cognitive complaints may be associated with lower reported quality of life. CONCLUSIONS: Results are largely consistent with previous findings on the effects of SRS in other clinical groups, which supports SRS as a targeted radiation treatment for AN.

Comparison of SMART and WHIM as measurement tools in routine assessment of PDOC patients.

BACKGROUND: Royal College of Physicians guidelines on PDOC recommended repeated assessments of patients in PDOC are undertaken by skilled clinicians. The Wessex Head Injury Matrix (WHIM) and the Sensory Modality Assessment and Rehabilitation Technique (SMART) are the most commonly used measures within UK. OBJECTIVE: To evaluate the use of WHIM and SMART to identify potential changes in PDOC patients. METHODS: Twelve PDOC patients admitted to a post-acute regional neuro-rehabilitation unit were assessed using WHIM and SMART. Eight of 12 patients were diagnosed with a primary hypoxic ischemic brain injury (HIBI). RESULTS: Overall for the total group there was no significant correlation between patient's highest ranked behaviour and any SMART domain. Initial WHIM total observed behaviour was significantly correlated with SMART tactile domain. Patient's final WHIM and SMART domains were not significantly correlated. Among HIBI subgroup, initial WHIM highest ranked behaviour and WHIM total observed behaviour were significantly correlated with the SMART communication domain. Final WHIM highest ranked behaviour was positively correlated with SMART visual and tactile domains. Final WHIM total observed behaviour was significantly correlated with the SMART visual domain. CONCLUSIONS: Both measures show sensitivity to change in PDOC patients. Larger long-term follow-up of HIBI patients is highlighted.

Impaired self-awareness after traumatic brain injury: inter-rater reliability and factor structure of the Dysexecutive Questionnaire (DEX) in patients, significant others and clinicians.

AIMS: This study sought to address two questions: (1) what is the inter-rater reliability of the Dysexecutive Questionnaire (DEX) when completed by patients, their significant others, and clinicians; and (2) does the factor structure of the DEX vary for these three groups? METHODS: We obtained DEX ratings for 113 patients with an acquired brain injury from two brain injury services in the UK and two services in Ireland. We gathered data from two groups of raters-"significant others" (DEX-SO) such as partners and close family members and "clinicians" (DEX-C), who were psychologists or rehabilitation physicians working closely with the patient and who were able to provide an opinion about the patient's level of everyday executive functioning. Intra-class correlation coefficients and their 95% confidence intervals were calculated between each of the three groups (self, significant other, clinician). Principal axis factor (PAF) analyses were also conducted for each of the three groups. RESULTS: The factor analysis revealed a consistent one-factor model for each of the three groups of raters. However, the inter-rater reliability analyses showed a low level of agreement between the self-ratings and the ratings of the two groups of independent raters. We also found low agreement between the significant others and the clinicians. CONCLUSION: Although there was a consistent finding of a single factor solution for each of the three groups, the low level of agreement between significant others and clinicians raises a question about the reliability of the DEX.

Impact of paroxysmal sympathetic hyperactivity on nutrition management after brain injury: a case series.

OBJECTIVE: To review the nutritional requirements of all new inpatient brain injury admissions presenting with Paroxysmal Sympathetic Hyperactivity (PSH) in the rehabilitation setting. METHODS: RABIU is a 25-bed Regional facility in Northern Ireland which opened in 2006. All records of patients with a single episode non-progressive acquired brain injury admitted to RABIU from 2006 until the present were reviewed for evidence of PSH. Dietetic assessment and management was examined and recorded. RESULTS: Four patients with persisting paroxysmal sympathetic hyperactivity were identified. All patients displayed dystonia and posturing and had clinically important percentage weight loss. All had nutrition and/or hydration requirements markedly above their estimated requirement for slow weight gain, despite adjustment for brain injury. All four had posture-related complications of their dystonia and nutrition. CONCLUSION: Careful monitoring of nutrition, hydration and mineral supplementation is paramount in patients presenting with paroxysmal sympathetic hyperactivity after brain injury. It is argued that morbidity may be reduced by aggressive and expert nutrition management.

Bladder continence management in adult acquired brain injury.

PURPOSE: Persistence of urinary incontinence post acquired brain injury (ABI) carries important prognostic significance. We undertook to document the incidence of urinary incontinence, its management and complications in rehabilitation inpatients following ABI and to assess adherence to post ABI bladder management guidelines. METHOD: A retrospective chart survey of a convenience sample of consecutive admissions to two adult neurorehabilitation units Forster Green Hospital, Belfast, and the Scottish Brain Injury Rehabilitation Service, Edinburgh (SBIRSE). Bladder continence and management on transfer to and discharge from rehabilitation, trial removal of catheter, use of bladder drill, ultrasound investigation, anticholinergic medication and complications were recorded. RESULTS: One hundred and forty six patients were identified. Seventy-seven (52.7%) were independent and continent of urine at rehabilitation admission and 109 (74.7%) on discharge. In all, 13 patients had urinary tract infection, 7 had urethral stricture and 1 developed haematuria whilst catheterised. Ultrasound of renal tracts was underused. Trial removal of catheter after transfer to rehabilitation occurred at a median of 10 days. CONCLUSIONS: Urinary continence was achieved in almost half of incontinent ABI patients during rehabilitation. There is potential for increased use of investigation of the renal tracts. Rehabilitation physicians should consider urethral stricture in the management of continence post ABI.

Botulinum toxin in gait dysfunction due to ankle clonus: a case series.

OBJECTIVES: Our purpose is to assess the effectiveness of Botulinum toxin (Btx) on gait dysfunction due to ankle clonus in neurological patients. METHODS: We use a retrospective case note review of 11 patients attending the Regional Acquired Brain Injury Unit (RABIU), Musgrave Park Hospital, Belfast, Northern Ireland. All patients had received Btx for the treatment of ankle clonus. Demographic data including diagnosis and time since neurological insult was collected. Information regarding walking speed and assistance required to walk before and after Btx treatment was analysed. RESULTS: In 10 of 11 patients, walking speed was significantly improved at 4-6 weeks post Btx injections (P = 0.006) and at 14-16 weeks post Btx injections (P = 0.005). Eight patients reduced their level of dependency on assistance. Subjective improvements in levels of pain, gait pattern and 'toe clawing' were also reported. CONCLUSIONS: Our findings suggest that Botulinum toxin has a role in treating ankle clonus in neurological patients, where it interferes in gait. Walking speed and level of dependence on others improved in this group.

Maintaining community living with post brain injury agitation: a role for sodium valproate.

BACKGROUND: There is limited evidence to support pharmacological interventions for post-brain injury agitation and aggression. CASE REPORT: The case of Patient A, a man with severe agitation and aggression post-brain injury, highlights the successful use of sodium valproate, in the maintenance of community living, which had been threatened by the breakdown of the care package for this lone-dwelling individual. CONCLUSIONS: The case uniquely illustrates the effect of the drug due to a washout period, albeit due to patient non-compliance, allowing comparative observations both on and off and again on medication. In addition, Patient A's aphasia brings to the fore the difficulty with managing such symptoms and the ability of aphasic persons to avail of services and neurobehavioural therapies.

Subarachnoid haemorrhage (SAH): long-term cognitive outcome in patients treated with surgical clipping or endovascular coiling.

PURPOSE: To compare long-term cognitive outcomes of patients treated with surgical clipping or endovascular coiling after subarachnoid haemorrhage (SAH). METHOD: Retrospective matched cohort study assessed neuropsychological functioning at least 12 months after aneurysmal SAH treatment. Fourteen patients treated by endovascular coiling and nine patients treated by surgical clipping participated. After gaining written consent, a comprehensive neuropsychological battery was completed. Standardised tests were employed to assess pre-morbid and current intellectual functioning (IQ), attention, speed of information processing, memory and executive function as well as psychosocial functioning and affect. RESULTS: Treatment groups were not significantly different in terms of age, pre-morbid IQ, time from injury to treatment or time since injury. A significant effect of treatment on full-scale IQ score (p = 0.025), performance IQ (p = 0.045) and verbal IQ score (p = 0.029), all favouring the coiled group was observed. A medium effect size between groups difference in immediate memory (p = 0.19, partial η(2) = 0.08) was also observed. No significant between group differences on attention, executive functioning and speed of information processing measures or mood and psychosocial functioning were noted. Both groups reported increased anxiety and memory, attention and speed of information processing deficits relative to normative data. CONCLUSIONS: Study findings indicate fewer cognitive deficits following endovascular coiling. Cognitive deficits in the clipped group may be due in part to the invasive nature of neurosurgical clipping. Further prospective research with regard to long-term cognitive and emotional outcomes is warranted. IMPLICATIONS OF REHABILITATION: • Treatment of ruptured intracranial aneurysms by either endovascualar coiling or neurosurgical clipping can result in significant long-term physical disability as well as cognitive impairment. • Observed cognitive impairment(s) tend to be less in patients following endovascular coiling. • Following ruptured aneurysm, patients with cognitive impairment report reduced health related quality of life and increased anxiety. • Those with identified cognitive impairment(s) may benefit from cognitive remediation.

Intensive physiotherapy for vegetative and minimally conscious state patients: a retrospective audit and analysis of therapy intervention.

PURPOSE: To analyse physiotherapy interventions and evaluate their effectiveness in the prevention and management of contracture with patients admitted in either vegetative or minimally conscious state in a UK Inpatient Regional Acquired Brain Injury Rehabilitation Service. METHOD: Retrospective audit of dependency levels and physiotherapy interventions in ten vegetative or minimally conscious state patients admitted over a 3-year period (2006-2009). Admission and discharge patient dependency status, Wessex Head Injury Matrix data and passive range of movement measurements on admission and discharge from physiotherapy were recorded. RESULTS: All patients presented with hypertonicity including contractures and all initially received a manual stretching/passive movement programme. Casting/splinting was employed in 8 cases and 7 received botulinum toxin injections. Standing regimes were initiated for 8 patients. No patient emerged out of either vegetative or minimally conscious state. Although they remained fully dependent for care needs, carer burden was reduced and all patients were able sustain a seating regimen. No minimal clinically important difference was observed in 85 out of 120 joint ranges measured (70.8%). Positive outcomes were observed in only 14 joints (11.7%) and negative outcomes in 21 joints (17.5%). CONCLUSION: At present, there is a paucity of evidence regarding physiotherapy efficacy to inform the management of patients in vegetative or minimally conscious state. Clearer agreed definitions of clinically important difference in passive range of movement are required to allow better interpretation of outcomes. Interventions should be aimed at minimising carer burden and developing individualised disability management programmes. Further research documenting the long-term outcomes in such patients is warranted.

Functional outcomes of decompressive hemicraniectomy following malignant middle cerebral artery infarctions: a systematic review.

Decompressive hemicraniectomy has been used increasingly in recent years to treat malignant middle cerebral artery territory infarction. This review examines functional outcome data, with the novel analysis of outcomes according to temporal periods post-surgery. Case series data were pooled to determine significant correlates of outcome. Severe disability was frequently the outcome among survivors within one month post-surgery. Time and rehabilitation were later reflected, with fewer deaths and the emergence of mild to moderate disability increasing in prevalence. Mortality and severe disability were consistently more probable with increasing age. Presurgical clinical status in the form of additional cerebral artery involvement and midline shift also correlated with mortality within the 30-day period post-stroke.

Analysis of Wessex Head Injury Matrix (WHIM) scores in consecutive vegetative and minimally conscious state patients.

Consensus guidelines defining minimally conscious state (MCS) have been available for some years. However, to date, few measures have been developed that are particularly suited to monitoring MCS patients and there are limited clinical outcome data. The objective of the study was to determine the value of serial repeated assessments using the Wessex Head Injury Matrix (WHIM) to identify changes in vegetative state (VS) and MCS patients. Twenty consecutive VS/MCS patients admitted to a post-acute regional neurorehabilitation unit were assessed using WHIM. Significant differences in both total number of behaviours observed (p < .001) and highest rank behaviour were observed (p = .001) between initial and final WHIM assessments. Preliminary findings suggest that the WHIM is a sensitive measure of subtle changes in VS and MCS patients.

Emotional distress and awareness following acquired brain injury: an exploratory analysis.

BACKGROUND: Symptoms of depression and anxiety are commonly reported following brain injury, providing ongoing challenges to patients, clinicians and carers. There is increasing interest in the influence of impaired awareness on emotional distress, supported by psychological investigations. OBJECTIVE: To explore the relationship between awareness and time since injury on reported emotional distress. METHOD: Awareness was assessed by comparing the reports of persons with brain injury to the reports of their treating clinicians and significant others. Fifty-four participants with acquired brain injury (ABI) completed the Awareness Questionnaire, the Dysexecutive Questionnaire and the Hospital Anxiety and Depression Scales. Clinicians and significant others completed the Awareness Questionnaire and the Dysexecutive Questionnaire in relation to each participant. RESULTS: Analyses of variance identified a main effect of awareness, such that participants with better awareness of their difficulties had higher emotional distress, regardless of time since injury. CONCLUSION: Findings support psychological theories suggesting that emotional distress is a response to the stressor of a brain injury and denial of difficulty, manifesting as impaired awareness, may play a protective role. They highlight the importance of understanding a patient's level of awareness so as to provide support aimed at minimizing the impact of distress on the rehabilitation outcome.